Pneumothorax Complicating Small‐bore Nasogastric Feeding Tube Insertion

To the Editor:—The value of enteral forms of alimentation has been appreciated for several decades. With the development of small-bore feeding tubes, the incidence of severe diarrhea, bloating, dehydration, and aspiration pneumonia has decreased. But with increased widespread usage of these small-bore feeding tubes, other complications have been noted. These include pharyngeal and esophageal perforations, as well as lodgement of the tube into the bronchi with subsequent intrapulmonary instillation of feeding solutions. We are reporting a case of pneumothorax following insertion of an 8 French feeding tube in an elderly male patient. We recommend certain guidelines which might lessen the risk of such a complication. A 93-year-old male nursing home resident was admitted for increasing difficulty in feeding. He was known to be suffering from a progressive dementia, likely senile dementia of the Alzheimer's type. He had clear lung fields, and there were flexion contractures of the lower extremities. His neurologic examination revealed lethargy and mental obtundation with disorientation as well as a decreased gag reflex. Attempts to feed the patient orally were unsuccessful and were further complicated by episodes of aspiration. An 8 French Entriflex flexible nasogastric feeding tube with a wire stylet (Biosearch Medical Products, Sommerville, NJ) was passed. Position was checked by insufflation of 20 to 30 mL of air and auscultation over the right upper quadrant and epigastrium. Aspiration did not reveal any fluid. Chest roentgenograms revealed the position of the tube to be in the right hemi-thorax. On examination there was no respiratory distress, but there were scattered right-sided rhonchi present. The tube was removed and reinserted successfully into the stomach. A repeat x-ray film of the chest revealed a small right pneumothorax, which resolved spontaneously, but on day 2 he developed bibasilar infiltrates with low-grade temperature elevations. He was given a 2-week course of clindamycin intravenously with a favorable response. He remained afebrile after the antibiotic was discontinued, but his general condition continued to deteriorate, and he died three days later. A postmortem examination was refused by the family. Nasopulmonary intubation is thought to be an infrequent but increasingly recognized complication of small-caliber flexible polyurethane and silicone rubber tube insertion with a metal stylet. In intensive care patients the incidence of such a complication is reported to be 0.3%.1 A review of the literature showed that the following risk factors were common among the patients with such a complication and should be considered high risk factors of nasopulmonary and nasopleural intubation: Altered sensorium; Absent gag reflex; Elderly patients; Debilitated conditions; Frequent prior insertions of nasogastric tubes; Patients with endotracheal tubes and trachiostomies; . Intensive care settings1–5 In two thirds of the reported cases, the complications of nasopulmonary or nasopleural intubation were recognized hours after the tube was inserted. Checking the position by auscultation if air is insufflated has been misleading.1,3,5 The manufacturer recommended x-ray confirmation of the position of the tube if uncertainty exists after the placement. Valentine and Turner1 emphasized the need of chest and abdominal roentgenograms following the feeding tube placement in every mentally obtunded patient. Lipman et al6 expressed reluctance and lack of cost effectiveness of routine x-ray verification of tube placement. Saltzberg et al2 stressed the value of utilizing fluoroscopic guidance in the proper placement of feeding tubes. They and others recommend this procedure for elderly patients who have impaired sensorium or neurologic deficits.2,3 It is apparent that the complications of nasopleural and nasopulmonary intubation with subsequent development of pneumothorax is not an isolated and very rare complication of small bore feeding tubes and that the following recommendations and guidelines may be of help in early recognition of such a potentially serious complication: Testing the pH of aspirated fluid in all patients should be attempted. A very low pH would be helpful corroborating evidence for proper placement of the tube into the stomach provided the patient is not on any antacids or H2-receptor blockers. Insufflation of 20 to 30 mL of air before a roentgenogram of the chest to verify the location of the feeding tube and to check for evidence of pneumothorax. Fluoroscopic guidance of feeding tube insertion in high-risk patients. If fluoroscopic guidance cannot be performed, and if uncertainty regarding proper placement of the feeding tube persists, introduction of a nontoxic radiocontrast medium such as Dionosil (5 to 10 mL) will document safe placement of the feeding tubes into the gastrointestinal tract.